Basic Information
| Provider Information | |||||||||
| NPI: | 1063574572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | EROSS | ||||||||
| FirstName: | ERIC | ||||||||
| MiddleName: | J | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4530 E MUIRWOOD DR STE 111 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850487693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809612365 | ||||||||
| FaxNumber: | 4809612382 | ||||||||
| Practice Location | |||||||||
| Address1: | 4530 E MUIRWOOD DR STE 111 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850487693 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4809612365 | ||||||||
| FaxNumber: | 4809612382 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/14/2006 | ||||||||
| LastUpdateDate: | 12/30/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/30/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 3626 | AZ | N | Other Service Providers | Specialist | 2084P0800X | 3626 | AZ | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084N0400X | 3626 | AZ | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | BE7162213 | 01 | DEA | OTHER | 3626 | 01 | AZ | LICENSE NUMBER | OTHER | 568462 | 05 | AZ | MEDICAID |